Endovascular surgeons at Penn Medicine are performing transcarotid artery revascularization (TCAR), a procedure with a hybrid approach to carotid stenting for the treatment of carotid artery stenosis.
Carotid artery stenosis is a cause of more than 40,000 strokes each year in the United States. Revascularization is performed to open vessels narrowed or obstructed by atherosclerotic plaque.
An Effective, Newer Carotid Intervention
Shang Loh, MD
Transcarotid artery revascularization, or TCAR, combines open surgery (a small incision at the common carotid artery) with percutaneous deployment of a specialized stent and arterial sheath connected to a neuroprotection system. Comprised of a dedicated venous sheath and flow-controller, the system has the object of preventing strokes during and after the procedure.
"TCAR is a very effective newer intervention that significantly reduces, and in many cases eliminates, the risk of a stroke or subsequent stroke in patents having carotid artery revascularization," says Shang Loh, MD. Dr. Loh is Chief of Vascular Surgery and Endovascular Therapy at Penn Presbyterian Medical Center, where he performs TCAR. TCAR surgeries are also being performed at the Hospital of the University of Pennsylvania and the Perelman Center for Advanced Medicine.
Comparative Advantages of TCAR in Carotid Artery Stenosis
The standard interventions for carotid revascularization include carotid endarterectomy and transfemoral carotid artery stenting (TF-CAS). TF-CAS is often combined with angioplasty.
An open procedure, carotid endarterectomy involves physical removal of atherosclerotic plaque. This procedure has been performed since the 1950s. TF-CAS is a percutaneous intervention wherein a stent originating at the femoral artery passes through the aortic arch to reach the carotids. Both approaches, but particularly endarterectomy, are associated with periprocedural stroke risk — which occurs when plaque debris is released into the carotid and rises to the brain.
TCAR avoids the risk of detritus flowing into the brain, Dr. Loh explains, by reversing the blood flow in the carotid through the neuroprotection system's manipulation of differential pressure within the arterial and venous systems.
"The result is that any atherosclerotic debris escaping into the vessel is drawn away from the brain where it can be filtered out of the blood," he says.
Who was TCAR Designed to Treat?
TCAR is an option for patients at a higher risk of complications from carotid endarterectomy due to age or other health issues.
Generally, TCAR can be an option for symptomatic patients with moderate carotid artery stenosis (>50%) and asymptomatic individuals with severe stenosis (>70%).
"While there are some anatomic reasons for exclusion, TCAR is available for a large subset of patients with carotid stenosis," Dr. Loh explains. He adds that the criteria for TCAR candidacy are best determined at evaluation.
TCAR Research at Penn Medicine
Grace J. Wang, MD, MSCE, FACS
Performed at Penn Medicine for several years, TCAR has been the focus of investigations led, in part, by Grace Wang, MD, MSCE, FACS, of Penn Vascular Surgery.
Dr. Wang is Director of the Vascular Laboratory at the Hospital of the University of Pennsylvania.
In 2019, Dr. Wang was the co-author of a study that found that TCAR was associated with a significantly lower risk of stroke or death by comparison to TF-CAS in patients with carotid artery stenosis. Dr. Wang also co-authored an international retrospective investigation in more than 18,000 patients having TCAR that concluded that TCAR was safe for younger individuals, and could be the preferred method for performing carotid stenting in women and older patients, particularly, older women.
TCAR is Available from the Following Penn Medicine Specialists
Penn Presbyterian Medical Center
Shang Loh, MD
Chief, Vascular Surgery and Endovascular Therapy, Penn Presbyterian Medical Center
Professor of Clinical Surgery
Hospital of the University of Pennsylvania
Nathan Belkin, MD
Assistant Professor of Surgery at the Hospital of the University of Pennsylvania
Alexander S. Fairman, MD
Assistant Professor of Surgery at the Hospital of the University of Pennsylvania
Grace J. Wang, MD, MSCE, FACS
Director, Vascular Laboratory, Hospital of the University of Pennsylvania
Associate Professor of Surgery at the Hospital of the University of Pennsylvania
Associate Professor of Radiology
Perelman Center for Advanced Medicine
Julia D. Glaser, MD
Assistant Professor of Clinical Surgery
Venkat R. Kalapatapu, MD
Residency and Fellowship Program Director, Vascular Surgery and Endovascular Therapy
Professor of Clinical Surgery
Darren B. Schneider, MD
Chief, Vascular Surgery and Endovascular Therapy
Clyde F. Barker - William Maul Measey Professor in Surgery
For more Information about TCAR at Penn Medicine
For case review or consult with a Penn Medicine endovascular surgeon who performs TCAR, please call our 24/7 provider-only line at 877-937-7366.
Submit a patient referral for TCAR evaluation through our secure online referral form.